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I was surprised how little attention this issue received in the media, given the size of the payments involved, and the extensiveness of the lists of those who received them. Demonstrating the anechoic effect, the issue received almost no attention in any medical or health care publications. Yet every now and then, the story resurfaces.

This week, it resurfaced courtesy the Philadelphia Inquirer, which published two related articles. The most vivid was about a lawsuit filed by a patient who received artificial hip implants that failed. MedInformaticsMD quoted relevant parts of the article and commented on some issues related to the above story here.

The Inquirer also published a companion story with background information on payments made by hip and knee implant manufacturers. Reporter Josh Goldstein took the opportunity to look into payments made to other Philadelphia area surgeons.

Locally, 29 doctors and others received a total of $7.9 million last year. Most of that money went to two of the region's busiest and most prominent orthopedic surgeons.

Richard H. Rothman, founder of the Rothman Institute at Thomas Jefferson University Hospital, received nearly $3 million last year from Stryker. A Rothman spokesman said most of that money came in royalty payments for a hip Rothman helped design.

The other surgeon, Robert E. Booth Jr., who practices at Pennsylvania Hospital, received nearly $2 million from Zimmer Corp., the company that makes the so-called gender knee for women. Booth is one of eight patent holders on it.

Both doctors declined to be interviewed. Through spokeswomen, they said they disclose their company ties to patients. There is no indication that either have engaged in any wrongdoing.

Indeed, many patients seek out surgeons like Booth and Rothman, who help design implants, precisely because they are known as pioneers in the field.

At 72, Rothman, the former chairman of orthopedic surgery at Jefferson, remains busy, replacing more than 600 hips and knees a year. Implants cost as much as $7,500 each.

According to Stryker's disclosures, the company paid Rothman $2.9 million in 2007. In addition, Rothman received $316,885 in "corporate assistance" for research, $52,906 in air travel, $4,705 for ground transportation, and $1,757 in meals.

'The vast majority of payments Dr. Rothman receives from Stryker are royalties for the Accolade hip implant,' said a statement provided by the practice he founded, the Rothman Institute.

At Pennsylvania Hospital, Booth, one of the nation's busiest knee surgeons, routinely replaces a knee in under a half hour - 12 to 14 a day, or about 1,200 a year.

Last year, Zimmer paid Booth $1.9 million, plus $35,729 in air travel, $3,135 for lodging, $1,214 for meals, and a $6 gift.

Susan E. Phillips, a senior executive at the University of Pennsylvania Health System, said Booth's contract with Zimmer prevents him from discussing royalties.

The articles focused on the question of whether these sorts of humongous payments were disclosed to patients, or whether they affected direct patient care by the surgeons who received them.

Since some breathtakingly huge payments were made to apparently very influential surgeons, I wondered if the surgeons disclosed such large payments to other doctors who might be influenced by their words.

In the articles I was able to quickly access published by Rothman during 2007, I found some disclosures of his relationship to Stryker, but none that revealed their magnitude. (These do not constitute a complete sample of his publications, just what I could easily obtain on the web.)

In support of their research for or preparation of this manuscript, one or more of the authors received grants or outside funding from Zimmer, Inc. In addition, one or more of the authors received payments or other benefits or commitment or agreement to provide such benefits from a commercial entity (Zimmer, Inc.) Also, a commercial entity (Zimmer, Inc.) paid or directed, or agreed to pay or direct, benefits to a research fund, foundation, educational institution, or other charitable or non-profit organization with which the authors are affiliated or associated.

In my humble opinion, a disclosure that a journal article's author received some sort of "grants" or "payments" from a company does not quite have the impact of a disclosure that the author received millions of dollars in royalties. My concern is that surgeons of the stature of those mentioned in these articles have numerous opportunities to influence the practice of their colleagues, by informal conversations, formal talks, and published writing. These colleagues at least should have the opportunity to decide for themselves whether the surgeons' enthusiasm for joint replacement, or for replacement in specific circumstances or with specific products, might just have been a bit influenced by making millions of dollars a year in royalties from specific joint implants.

Again, there has been a lot of discussion lately about the effects of small gifts, pens, mugs, and pizza lunches, on physicians. Even small gifts have been shown to influence how people think and act. But if small gifts have some effect, what sort of effect would arise from royalty payments enough to make a doctor quite rich? Inquiring minds want to know.

Placing this in the context of my local hospital we see hip and knee replacements as almost a rite of passage. Our two local hospitals both have cath labs in the ER and it is amazing how many folks need this service when admitted, for any reason.

Against this backdrop we have a June 17, 2008, Akron Beacon Journal article highlighting the continuing legal suits against Aultman Hospital by Mercy Medical regarding $8.9M in "conversion" payments made by Aultman's for profit insurance company. Aultman has also been under scrutiny for some of it's insurance practices. The Ohio Dept. of Insurance has found no laws were broken with these payments.

Canton is an aging rust belt city with many older people covered by legacy medical policies from manufacturing companies. You will find an attitude that these people feel "owed" free and unlimited medical care. Medicine is considered a growth industry, and while we have a declining population, we have had an increase in the number of doctors in our area.

It is not hard to figure out why we in America spend the highest amount of GDP on medical cost, but do not offer universal coverage or enjoy improved mortality when the medical community only focus seems to be on getting as much as possible from the system.

Much like the seagulls in Finding Nemo the only work they know is "mine."

The "conversion" fees paid by Aultman's for profit insurance company were paid above the normal commission rate, and are being viewed as an incentive to switch clients to policies that may in fact not be in their best interest.

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